Provider Demographics
NPI:1013093616
Name:NATIONAL MENTOR HEALTHCARE NETWORK
Entity Type:Organization
Organization Name:NATIONAL MENTOR HEALTHCARE NETWORK
Other - Org Name:FLORIDA MENTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-388-5150
Mailing Address - Street 1:313 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-1218
Mailing Address - Country:US
Mailing Address - Phone:800-388-5150
Mailing Address - Fax:617-790-4271
Practice Address - Street 1:4550 RICKER RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-6308
Practice Address - Country:US
Practice Address - Phone:904-778-0935
Practice Address - Fax:904-778-8396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2023-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL4060096320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018500800Medicaid
FL031258400Medicaid